Patient Registration

For your convenience, you can complete your Patient Registration Form online below.

The information submitted via this form is sent over a secure https SSL connection.

Patient Registration

Patient Details

Next of Kin/ Emergency Contact

Medicare and Health Fund Details

The number directly in front of your name. Eg 1
Do you have Private Health Insurance?
Do you have a Pension Card?
Do you have a DVA card?

Referrer Details

Is this your usual Doctor / GP?

Select a Specialist

Please select the specialist you have been referred to

Allied Health

Please select the specialist you have been referred to

Medical Information & History

Are you taking any medications that thin the blood (if so, please select)
Are you Diabetic?
Please select type of diabetes
Are you taking any of the diabetic medication below (if so, please select)

Final Step

Maximum file size: 10MB

Max. file size is 10mb. (Following files only. jpg, jpeg, png , gf, xls, doc, docm, docx, pages, pdf)

Privacy Statement and Consent

As a patient of Sydney Colorectal Associates a medical record containing personal information will be maintained throughout your treatment. These records will contain information including, but not exclusive to, your name, address, date of birth, Medicare number and your referring doctor’s details. During the period of assessment and ongoing management, information of relevance is recorded in clinical notes. These records are stored securely and may be kept for up to seven years following your last consultation. If necessary, for the continuity of your medical care, this information may be shared with other health practitioners involved in your treatment. In certain circumstances there may be a legal obligation to disclose clinical information. A full copy of our privacy policy is available on request.

I hereby give my permission for Sydney Colorectal Associates Pty Ltd to pass on and to seek medical information from any medical practitioner, who has referred, treated or will treat me as long as the exchange of information is necessary for my medical treatment. I give my permission for Sydney Colorectal Associates to undertake tissue banking of pathology specimens from any procedures I may need to undergo; (de-identified) photography/recording of procedures I may need to undergo for educational, clinical and audit purposes; presentation of my (de-identified) clinical facts at educational or scientific meetings and in journals; and/or presentation of my (identifiable and linkable) clinical facts and discussion at multidisciplinary meetings that are presented for the purpose of optimising my clinical management.

I also give my permission for Sydney Colorectal Associates to use Medicare Online Claiming and/or electronic account transmission on my behalf when required, and I assign my right to Medicare benefits to the Practitioner who rendered the service/s.

I also give my permission for Sydney Colorectal Associates to send correspondence by post/SMS/email to help me maintain my health.

I acknowledge and understand that if there are any changes to the information provided above, it is my responsibility to inform Sydney Colorectal Associates to help me protect my privacy.

I acknowledge and understand that there may be out-of-pocket costs for services provided and that it is my responsibility to confirm with Medicare and/or my insurer (if any) as to my eligibility and the amount of any reimbursement, and if a procedure is necessary during my consultation, there may be an associated cost in addition to the standard consultation fee.

I consent to fees of $50 for a consultation and/or $200 for a procedure. If I need to cancel my appointment, I will provide at least 48 hours’ notice. If I fail to notify the clinic or do not attend my appointment, I understand that I will be charged the above fees, which are not eligible for Medicare rebates. Furthermore, I acknowledge that I will be restricted from making any future bookings until my account is settled.

Appointments & Enquries

Our goal at Sydney Colorectal Associates is to deliver prompt access to appointments, diagnostic services and procedures that are tailored to your requirements.